Recurrent strokes and memory loss in a patient with triple-positive antiphospholipid antibody syndrome

Antiphospholipid syndrome may cause recurrent thromboembolic events of the microvasculature, arteries and veins. It is also characterised by a range of neurological and psychiatric dysfunctions, as well as complications during pregnancy. Patients with triple-positive antiphospholipid syndrome have persistently elevated levels of lupus anticoagulant (LA), anti-beta-2-glycoprotein I (B2GPI) and anticardiolipin antibodies (aCL). These patients also have a higher risk of initial or recurrent thrombosis.We report the case of a 36-year-old man who was presented with progressive memory loss and recurrent stroke. He had persistently elevated antiphospholipid antibody titres (LA, aCL-immunoglobulin G and B2GPI antibodies). These features persisted while the patient was receiving low-dose aspirin (LDA), 81mg daily. Vitamin K antagonist (VKA); warfarin, with the international normalised ratio (INR) maintained at 2-3 was then added to his treatment regimen. The VKA dose was maintained at - a higher therapeutic INR while LDA administration was continued to achieve resolution of the patient's symptoms.

Implementing Treat to Target (TTT) for Rheumatoid Arthritis (RA) During COVID: Results of a Virtual Learning Collaborative (LC) Program

Objective

A treat‐to‐target (TTT) approach improves outcomes in rheumatoid arthritis (RA). In prior work, we found that a learning collaborative (LC) program improved implementation of TTT. We conducted a shorter virtual LC to assess the feasibility and effectiveness of this model for quality improvement and to assess TTT during virtual visits.

Methods

We tested a 6‐month virtual LC in ambulatory care. The LC was conducted during the 2020–2021 COVID‐19 pandemic when many patient visits were conducted virtually. All LC meetings used videoconferencing and a website to share data. The LC comprised a 6‐hour kickoff session and 6 monthly webinars. The LC discussed TTT in RA, its rationale, and rapid cycle improvement as a method for implementing TTT. Practices provided de‐identified patient visit data. Monthly webinars reinforced topics and demonstrated data on TTT adherence. This was measured as the percentage of TTT processes completed. We compared TTT adherence between in‐person visits versus virtual visits.

Results

Eighteen sites participated in the LC, representing 45 rheumatology clinicians. Sites inputted data on 1,826 patient visits, 78% of which were conducted in‐person and 22% of which were held in a virtual setting. Adherence with TTT improved from a mean of 51% at baseline to 84% at month 6 (P for trend < 0.001). Each aspect of TTT also improved. Adherence with TTT during virtual visits was lower (65%) than during in‐person visits (79%) (P < 0.0001).

Conclusion

Implementation of TTT for RA can be improved through a relatively low‐cost virtual LC. This improvement in TTT implementation was observed despite the COVID‐19 pandemic, but we did observe differences in TTT adherence between in‐person visits and virtual visits.

Janus Kinase Inhibitors and Risk of Venous Thromboembolism: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the risk of venous thromboembolism (VTE) in patients treated with Janus kinase (JAK) inhibitors in clinical trials.

PATIENTS AND METHODS

We performed a literature search of Ovid MEDLINE and ePub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily; Ovid EMBASE; Ovid Cochrane Central Register of Controlled Trials; Ovid Cochrane Database of Systematic Reviews; and Scopus, from inception to December 4, 2019, for randomized, placebo-controlled trials with JAK inhibitors as an intervention and reported adverse events. Odds ratio with 95% CI was calculated to estimate the VTE risk using a random effects model. Two independent reviewers screened and extracted data. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess certainty in estimated VTE risk.

RESULTS

We included 29 trials (13,910 patients). No statistically significant association was found between use of JAK inhibitors and risk of VTE (odds ratio, 0.91; 95% CI, 0.57 to 1.47; P=.70; I²=0; low certainty because of serious imprecision). Results using Bayesian analysis were consistent with those of the primary analysis. Results of stratified and meta-regression analyses suggested no interaction by dose of drug, indication for treatment, or length of follow-up.

CONCLUSION

We found insufficient evidence to support an increased risk of JAK inhibitor-associated VTE based on currently available data.

Medical overuse of therapies and diagnostics in rheumatology

Medical overuse leads to a burden on healthcare costs and potentially is harmful to patients. We wanted to address medical overuse in musculoskeletal disease and rheumatology. We performed a systemic literature review from PubMed and Embase to study medical overuse. On the initial screen, 1499 studies were identified, 839 of them were related to medical overuse. Out of these, 52 were related to overuse in musculoskeletal diseases. Finally, 20 articles were chosen for this systemic review that reported overuse in rheumatology. The article identifies issues with overtesting, including the use of dual-energy X-ray absorptiometry to screen for osteoporosis in women younger than 65 years old and the use of magnetic resonance imaging to evaluate for osteoarthritis. Studies related to overtreatment reported over-prescription of vitamin D supplements resulting in vitamin D toxicity and increased risk of inappropriate prescriptions in patients with osteoarthritis and rheumatoid arthritis. Overtreating osteoporosis was reported after industry-sponsored education. Articles describing methods to reduce overuse included a study showing the reduction of unnecessary dual-energy X-ray absorptiometry scans after the introduction of the Choosing Wisely Campaign. Our findings suggest that there is some evidence that overtesting and overtreatment may be present in the field of rheumatology. This review aims to highlight this and help rheumatologists to be aware of overuse practices and provide appropriate evidence-based healthcare.

Health-related risk behaviors among myocardial infarction survivors in the United States: A propensity score matched study

BACKGROUND

According to the American College of Cardiology/the American Heart Association (ACC/AHA) recommendations, health-related risk behaviors for secondary prevention of myocardial infarction (MI) are critical to determine.

OBJECTIVE

This study aimed to compare health-related risk behaviors between MI survivors and propensity-score-matched non-MI controls using nationally representative data.

METHODS

This cross-sectional, matched case-control study used publicly available Behavioral Risk Factor Surveillance System (BRFSS) 2017 data. Older adults with MI were propensity-score-matched to their non-MI controls. The 10 dependent variables included body mass index (BMI), smoking status, heavy alcohol consumption, influenza vaccine, length of time since last routine and cholesterol checkup, alcohol consumption, fruit and vegetable consumption, and physical activity. Chi-square tests and binomial logistic regression were used to examine the health-related risk behaviors differences between MI survivors and propensity-score-matched non-MI controls.

RESULTS

The final study sample consisted of 18,021 MI survivors and 54,063 non-MI controls after propensity score matching. Multivariable logistic regression analysis showed significant differences between MI survivors and matched non-MI controls in terms of cholesterol checkup, smoking status, and alcohol consumption. For example, multivariate analysis of health-related risk behaviors showed MI survivors were more likely to be smokers (AOR = 1.46, 95% CI: 1.28-1.68).

CONCLUSION

Based on this national survey of adults, MI survivors were more likely to be smokers but less likely to consume alcohol compared to their propensity-score-matched controls. Moreover, MI survivors were more likely to have their cholesterol checkup within the past 2 years compared to matched non-MI controls. Although lower alcohol consumption and greater chances of cholesterol checkups are reassuring health-related behaviors, interventions are needed to minimize the chances of smoking in this population.

The Influence of Depression on Health Care Expenditures Among Adults with Spondylosis, Intervertebral Disc Disorders, and Other Back Problems in the United States

BACKGROUND

Back pain is a very prevalent complaint, affecting two-thirds of the US population, and it accounts for $100 billion annually in health care expenditures. The occurrence of depression has been reported in existing literature among patients with back pain, but there is limited information regarding health care expenditures among patients with back pain and concurrent depression.

OBJECTIVE

To assess excess total and subtypes of health care expenditures among adults with spondylosis, intervertebral disc disorders, and other back problems who reported having depression compared with those without depression in the United States.

METHODS

We utilized a cross-sectional design, pooling Medical Expenditure Panel Survey data from 2010-2012. The eligible study sample included adults (age ≥18 years) who reported positive health care expenditure. Total and subtypes of health care expenditures constituted the dependent variable. Ordinary least squares (OLS) regressions on logged expenditures were performed. Four models were developed to assess influence of demographics, functional ability, and concurrent diagnoses on health care expenditures.

RESULTS

A total of 6,739 adults with spondylosis, intervertebral disc disorders, and other back problems were assessed, 20.2% (N = 1,316) of whom had concurrent depression. Adults with concurrent depression had significantly higher total health care expenditures ($13,153) compared with the nondepression group ($7,477, P < 0.001). Outpatient and prescription expenditures showed similar findings. After adjusting for demographics, functional disabilities, and comorbidities, excess cost remained higher in the group reporting concurrent depression (46%).

CONCLUSIONS

This study demonstrates that the presence of depression in adults with spondylosis, intervertebral disc disorders, and other back problems is associated with greater economic burden. These findings remained consistent after adjusting for all independent sets of variables. The study's findings suggest that interventions resulting in better management of depression have the potential to significantly reduce the economic burden in this population.

Risk of Infections and Cancer in Patients With Rheumatologic Diseases Receiving Interleukin Inhibitors: A Systematic Review and Meta-analysis

IMPORTANCE

The safety profile of interleukin (IL) inhibitors is not well established.

OBJECTIVE

To assess the risk of serious infections, opportunistic infections, and cancer in patients with rheumatologic diseases treated with IL inhibitors.

DATA SOURCES

Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations; Ovid MEDLINE Daily; Ovid Embase; Ovid Cochrane Central Register of Controlled Trials; Ovid Cochrane Database of Systematic Reviews; and Scopus were searched (inception to November 30, 2018).

STUDY SELECTION

Randomized, placebo-controlled trials that evaluated IL inhibitor therapies in rheumatic diseases and reported safety data were included in the analyses.

DATA EXTRACTION AND SYNTHESIS

This systematic review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Two investigators independently extracted study data and assessed risk of bias and certainty in the evidence. Fixed-effects meta-analysis was conducted to pool odds ratios (ORs) for serious infections, opportunistic infections, and cancers for IL inhibitors vs placebo.

MAIN OUTCOMES AND MEASURES

The outcomes of interest were the number of serious infections, opportunistic infections, and cancers in individuals receiving IL inhibitor therapies compared with placebo.

RESULTS

In this meta-analysis, 74 studies comprising 29 214 patients (24 236 patients for serious infections, 9998 for opportunistic infections, and 21 065 for cancer [number of patients overlaps for each outcome]) were included. Patients receiving IL inhibitors had a higher risk of serious infections (OR, 1.97; 95% CI, 1.58-2.44; P < .001, I2 = 0%; high certainty), opportunistic infections (OR, 2.35; 95% CI, 1.09-5.05; P = .03, I2 = 0%; moderate certainty), and cancer (OR, 1.52; 95% CI, 1.05-2.19; P = .03, I2 = 11%; moderate certainty).

CONCLUSIONS AND RELEVANCE

The risk of serious infections, opportunistic infections, and cancer appears to be increased in patients with rheumatologic diseases who are treated with IL inhibitors compared with placebo.

Healthcare expenditures among community-dwelling adults with thyroid cancer in the United States: A propensity score matched analysis

Objective

This study assessed the excess healthcare expenditures and factors associated with it among community-dwelling adults with thyroid cancer compared to non-cancer controls in the United States.

Method

A retrospective, cross-sectional, matched case-control study design was used by pooling multiple years of Medical Expenditure Panel Survey (MEPS) data (2002–2012). The eligible study sample comprised of adults (age ≥18 years), who were alive during the calendar year and reported positive healthcare expenditure. The case group consisted of adults with thyroid cancer only while the control group consisted of adults who did not have any form of cancer. Total and subtypes of mean annual healthcare expenditures comprised the main study outcome. We also calculated the total and subtypes of out-of-pocket (OOP) expenditures as well as OOP as a percentage of household income. Ordinary Least Square (OLS) regressions on log-transformed expenditures were conducted to elucidate the influence of different factors on healthcare expenditures among adults with thyroid cancer.

Results

The yearly average total healthcare expenditures among adults with thyroid cancer was significantly higher compared to propensity score matched controls ($9,585 vs. $5,830, p < 0.001). Similar observations were found in terms of inpatient, and outpatient expenditures. Functional status as well as comorbid conditions were significantly associated with excess expenditures. The yearly average total OOP expenditure for adults with thyroid cancer was significantly higher compared to matched controls ($1,425 vs. $974, p < 0.001), with major differences observed in inpatient OOP ($178 vs. $24, p = 0.003), outpatient OOP ($435vs. $256, p < 0.001), and prescription OOP ($554 vs. $423, p < 0.001) expenditures. There was a significant (p < 0.001) difference between the average OOP as a percentage of household income between adults with thyroid cancer (Mean: 7.54%, S.E: 1.52%) and matched controls (Mean: 5.80%, S.E: 0.47%).

Conclusions

Our findings suggest that holistic care approach could be helpful to significantly reduce the economic burden in this population. Viable strategies such as limits on OOP costs are required to minimize this high OOP burden among cancer survivors and their families.

The 100 top-cited publications in psoriatic arthritis: a bibliometric analysis

BACKGROUND

Citation analysis is a quantitative, bibliometric method that analyzes the frequency and pattern of citations in any given scientific discipline. Over the last two decades, the study of psoriatic arthritis has undergone substantial progress, which has enhanced our ability to assess and treat the disease, and yet an updated citation analysis that reflects these advances is lacking.

OBJECTIVE

To highlight the scientific progress in psoriatic arthritis by identifying and analyzing the 100 top-cited psoriatic arthritis articles from the last 40 years.

METHODS

Publications on psoriatic arthritis were identified using the Scopus citation database and Web of Science. No date range limits were applied. Data on the 100 top-cited publications were extracted and analyzed.

RESULTS

Of the 100 top-cited publications, the median number of citations per publication was 265.9. Articles originated from 29 different countries. Publication dates ranged from 1973 to 2014. The majority (n = 88) were published after 1994, and the greatest number of highly cited psoriatic arthritis publications were reported between 2001 and 2007 (n = 36). Journals with the highest number of top-cited articles included Arthritis and Rheumatology (formerly Arthritis and Rheumatism) (n = 26), followed by Annals of Rheumatic Diseases (n = 21) and Journal of Rheumatology (n = 11). The top six journals with the most highly cited psoriatic arthritis articles were rheumatology journals, with the exception of the Journal of American Academy of Dermatology, a dermatology-based periodical. General medical journals published only nine of the 100 top citations. Impact factors ranged from 2.133 to 44.002, with a mean impact factor of 9.103. There were five authors with 10 or more highly cited psoriatic arthritis publications and 30 authors with five or more of the top publications. Subgroup analysis of the top 25 articles included nine randomized clinical trials, nine observational studies, five reviews, and two guideline statements. Additional subgroup analysis identified the top five hallmark trials in the field. Key publications provided data on classification criteria, disease prevalence, patterns of clinical and radiographic presentation, disease outcomes, associated cardiovascular disease risk, immunologic features and HLA associations, and efficacy and therapeutic benefit of TNFα inihbitors, interleukin-12/23 antagonists, and sulfasalazine.

CONCLUSIONS

The study of psoriatic arthritis is rapidly evolving. This bibliometric analysis delineates the landmark publications in psoriatic arthritis that have defined innovative therapeutic modalities and provided critical reviews, guidelines, and other key studies, which highlight the important progress made in the field.

Psoriasis and Psoriatic Spectrum Disease: A Primer for the Primary Care Physician

Psoriasis is a chronic, immune-mediated disorder that affects approximately 7.5 million people in the United States. Individuals with psoriasis may develop cutaneous, articular, and systemic manifestations, which are a source of significant morbidity and a heightened risk of mortality, and may adversely impact patient-reported quality of life measures. Psoriasis is now recognized as a risk factor for cardiovascular disease, metabolic syndrome, peripheral vascular disease, inflammatory bowel disease, certain malignancies, and chronic renal disease. Therefore, it has become increasingly relevant that primary care physicians have a basic working knowledge and an understanding of fundamental management principles of psoriasis. This review highlights the salient clinical features of psoriasis and psoriatic spectrum disease, emphasizing key updates with respect to systemic disease and associated conditions, and briefly outlines a therapeutic algorithm for the primary care physician.

Low-Dose d-Amphetamine Induced Regression of Liver Fat Deposits in Dercum Disease

BACKGROUND

Dercum disease is a rare disorder of painful subcutaneous adipose tissue masses typically presenting as a constellation of signs and symptoms affecting most organs, including slow lymphatic flow and fatty liver.

METHOD

The University of Arizona Institutional Review Board considered this report exempt after patient consent. Multislice, multisequence magnetic resonance imaging (MRI) of the abdomen and pelvis was performed prior to and after d-amphetamine, with and without intravenous gadolinium.

RESULTS

Initial MRI demonstrated hepatic steatosis in Case 1; Case 2 had 2-subcentimeter lipid foci within the liver. Initiation of 10-20 mg d-amphetamine decreased liver lipid deposition from 16% to 4% in Case 1 and resolved fat deposits in Case 2 after ~1 year.

CONCLUSION

There is a dire need for novel treatment options for nonalcoholic fatty liver disease to prevent progression to cirrhosis. Reduction of liver fat by d-amphetamine suggests a potential therapeutic role in nonalcoholic fatty liver disease.

Health Behaviors among Stroke Survivors in the United States: A Propensity Score-Matched Study

GOAL

The American Heart Association/American Stroke Association has specific recommendations for secondary stroke prevention. The aim of this study was to compare health behaviors engagement between stroke survivors and propensity score-matched controls.

METHODS

We conducted a retrospective, cross-sectional, matched case-control study using data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) survey. We included older adults aged 50 or older who participated in the 2015 BRFSS survey and completed the interview. Each case was matched to 3 controls (1:3) based on propensity scores to increase the power of the analyses. Stroke survivors were compared with controls on their physical activity, smoking, alcohol use, body mass index (BMI), last flu immunization, last physical checkup, last blood cholesterol check, heavy drinking, and vegetable and fruit consumption. We used binomial logistic regression to assess health behaviors among stroke survivors compared with controls.

RESULTS

The final study sample consisted of 13,249 stroke survivors and 39,747 controls without stroke after propensity score matching. Multivariable analyses revealed that there were significant differences between stroke survivors and matched controls in terms of BMI, physical activity, smoking status, alcohol consumption, and vegetable and fruit consumption. For example, stroke survivors were 51% more likely to be smokers (adjusted odds ratio [AOR] 1.51, 95% confidence interval [CI], 1.32-1.73) and 14% less likely to consume alcohol (AOR .86, 95% CI .78-.95).

CONCLUSION

Findings from our study indicate that compared with propensity score-matched controls, stroke survivors engage in poorer health behaviors with the exception of alcohol consumption.

Disease Milestones through Bibliometric Analysis of the Top 100 Cited Articles in Multiple Myeloma

Multiple myeloma (MM) accounts for 1.6% of all cancers and 5%-10% of all hematologic malignancies in the United States (US). Despite marked progress in disease management, it remains incurable with high rates of relapse. We conducted a bibliographic analysis on the Web of Science (WOS) from July 25, 2017 and July 29, 2017. Among the top 100 most-cited articles (1901-2012), the most cited article received 2404 citations and least cited article received 336 citations. Forty-four of 100 articles were published in journals with impact factors greater than 20. We observed that over the years, the focus of research has shifted from diagnosis, staging, and pathogenesis to better treatment outcomes. A subgroup analysis of the top 100 cited articles published in the last five years (2012-2017) demonstrated that several landmark studies, which will likely change the landscape of treating multiple myeloma, were not included in the top 100 list. Interestingly, most of these articles were focused on novel therapeutic agents. This bibliographic analysis provides a list of the 100 top-cited articles in multiple myeloma along with the captivating comprehension of the history and development in various aspects of disease processes. The landscape of this disease is rapidly evolving, and bibliometric studies such as the one presented provide a valuable tool that can highlight the important transitions in the field.

A systematic review and meta-analysis of the efficacy and safety of the interleukin (IL)-12/23 and IL-17 inhibitors ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab and tildrakizumab for the treatment of moderate to severe plaque psoriasis

OBJECTIVE

To systematically analyze the efficacy and safety of interleukin (IL)-12/23, IL-17, and selective IL-23 inhibitors in moderate to severe plaque psoriasis.

METHODS AND RESULTS

Twenty-four randomized placebo-controlled trials were included. Compared to placebo, risk ratios (RR) of achieving PASI-75 and PGA/IGA 0/1 respectively were 20.20 (95% CI 13.82-29.54, p < .00001) and 14.55 (10.42-20.31, p < .00001) for ustekinumab 90 mg, 13.75 (8.49-22.28, p < .00001) and 9.81 (5.70-16.89, p < .00001) for ustekinumab 45 mg, 17.65 (12.38-25.17, p < .00001) and 26.13 (16.05-42.53, p < .00001) for secukinumab 300 mg, 15.36 (10.76-21.94, p < .00001) and 20.91 (12.82-34.13, p < .00001) for secukinumab 150 mg, 18.22 (10.63-31.23, p < .000001) and 18.82 (10.36-34.16, p < .00001) for ixekizumab 80 mg every 4 weeks, 19.83 (11.07-35.52, p < .00001) and 20.41 (11.01-37.81, p < .00001) for ixekizumab 80 mg every 2 weeks, 14.79 (9.86-22.16, p < .00001) and 21.93 (15.52-31.01, p < .00001) for brodalumab 210 mg, 11.55 (7.77-17.18, p < .00001) and 16.59 (11.72-23.49, p < .00001) for brodalumab 140 mg, 12.40 (8.87-17.34, p < .00001) and 10.84 (7.91-14.85, p < .00001) for guselkumab 100 mg, 11.45 (7.45-17.58, p < .00001) and 10.97 (6.44-18.69, p < .00001) for tildrakizumab 200 mg, 11.02 (7.17-16.93, p < .00001) and 10.03 (6.45-15.59, p < .00001) for tildrakizumab 100 mg. Similar outcomes were seen for PASI-90. Safety was satisfactory for each therapy at any dose, but a slightly increased risk of withdrawal due to toxicity was observed in individuals receiving ixekizumab compared to placebo.

CONCLUSION

Ustekinumab, secukinumab, ixekizumab, brodalumab, guselkumab, and tildrakizumab were highly efficacious and generally well-tolerated when used as treatments for moderate to severe plaque psoriasis.

Advanced gastric cancer linitis plastica presented with disseminated intravascular coagulation

An old man was found unconscious; on admission found to have disseminated intravascular coagulation with concern of upper gastrointestinal bleed after he was found to have melena. Esophagogastroduodenoscopy on admission showed diffuse thickened gastric folds, and biopsy showed mucosal oedema. Bone marrow biopsy concerning for lymphoma was obtained showed adenocarcinoma. MRI of the abdomen was significant for diffuse gastric wall thickening. A repeat endoscopic ultrasound showed a diffuse gastric wall thickening of 15 mm and submucosal tunneling technique biopsy suggested high-grade, invasive, signet ring adenocarcinoma of the stomach. Oncology was consulted to initiate palliative chemotherapy. In retrospect, the patient was questioned regarding gastrointestinal symptoms; he reported gradual early satiety, dysphagia and unintentional weight loss over the course of 4 months.

Meta-analysis of revascularization versus medical therapy for atherosclerotic renal artery stenosis

The aim of the study was to compare the efficacy of revascularization versus medical therapy in patients with atherosclerotic renal artery stenosis (ARAS). ARAS is the most common cause of secondary hypertension and is associated with several complications, such as renal failure, coronary artery disease, cardiac destabilization, and stroke. Medical therapy is the cornerstone for management of ARAS; however, numerous trials have compared medical therapy with revascularization in the form of percutaneous renal artery angioplasty (PTRA) or percutaneous renal artery angioplasty with stent placement (PTRAS). Medline (PubMed and Ovid SP), Embase, Cochrane Central Register of Controlled Clinical Trials (CENTRAL), and Cochrane Database of Systematic Review (CDSR) were searched till present (November 2013) to identify clinical trials where medical therapy was compared with revascularization (PTRA or PTRAS). We performed a meta-analysis using a random effects model. The heterogeneity was assessed using I2 values. The initial database search identified 540 studies and 7 randomized controlled trials, and 2,139 patients were included in the final analysis. Angioplasty with or without stenting was not superior to medical therapy with respect to any outcome. The incidence of nonfatal myocardial infarction was 6.74% in both the stenting and medical therapy group (odds ratio=0.998, 95% confidence interval 0.698 to 1.427, p=0.992), and incidence of renal events in stenting population was found to be 19.58% versus 20.53% in medical therapy (odds ratio=0.945, 95% confidence interval 0.755 to 1.182, p=0.620). In conclusion, PTRA or PTRAS does not improve outcomes compared with medical therapy in patients with ARAS. Future studies should investigate to identify patient subgroups that may benefit from such an intervention.